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For urgent or emergent medical needs, please call 911 or visit your nearest emergency department. Our online appointment request forms are intended for non-urgent appointments only.

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Psychiatry

$240

Initial Visit

$120

Follow Up

Therapy

$150

Initial Visit

$150

Follow Up

Please fill in the form below.

Personal details

Legal First name*

Legal Last name*

Mobile*

Email address*

Gender at birth*

Referred by*

Date of birth*Address*

City*

State*

Zip code*

Emergency Contact Name*

Phone No

Emergency Contact Relationship

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Name of person completing form and relationship to patient*Reason for appointment*Current medications and dosage*List any medical allergies*Primary Care Physician (Name, Phone, Address)Preferred Pharmacy

Name

Phone No

Address

City

State

Zip

Is patient a minor?*YesNo

Is patient a minor?*

Legal Guardian(s) (if applicable)

Preferred Phone No

CellHomeWork

Secondary Phone No

CellHomeWork

Email AddressPatient/Guardian's Name

Patient/Guardian's Signature

Date

Do you have any current or pending legal issues or are being advised by a court judge,parole officer, or CPS to seek mental health care or assessment?*YesNoPlease select if you have ever experienced or suffered from any of the following in the past or present? (check one or all that applies)
Thoughts of harming others*PastPresentNoSuicide ideation*PastPresentNoAlcohol abuse*PastPresentNoSubstance abuse*PastPresentNoAre you using insurance?*YesNo

Insurance provider*Insurance ID*Group #(if applicable)Please upload a picture of the front and back of your insurance card.

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Disclaimer: Self-paying patients have to pay their balance prior to their appointment.

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Contact Us

3400 Douglas Blvd.
Suite 170 Roseville, CA 95661

Phone:
(855) 446-8628

Email:
info@telemed2u.com

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